What is a recommended tapering schedule for Nabilone (Cesamet) 0.5 mg three times a day (TID)?

Nabilone Tapering Schedule

For nabilone 0.5 mg TID (1.5 mg total daily dose), reduce by 0.5 mg every 2 weeks, transitioning to extended interval dosing before complete discontinuation to minimize withdrawal symptoms and CNS irritability.

Recommended Tapering Protocol

Gradual dose reduction is essential because abrupt discontinuation of CNS-active medications can cause withdrawal symptoms, similar to other centrally-acting agents like baclofen. 1

Step-by-Step Tapering Schedule

• Week 1-2: Reduce to 0.5 mg BID (1.0 mg total daily)—eliminate one daily dose 1
• Week 3-4: Reduce to 0.5 mg daily (0.5 mg total daily)—eliminate second daily dose 1
• Week 5-6: Transition to 0.5 mg every other day for 2 weeks 2
• Week 7-8: Transition to 0.5 mg every 4 days for 2 weeks before complete discontinuation 2

This schedule follows the principle that slow tapering should be performed to increase overall outcomes and minimize adverse effects, with dose reductions approximately every 2 weeks. 1

Monitoring During Tapering

Watch closely for withdrawal symptoms and adverse effects at each dose reduction before proceeding to the next step. 1

Key Symptoms to Monitor

• CNS effects: Dizziness, drowsiness, lightheadedness, ataxia (occur in 60-70% of patients on therapeutic doses) 3, 4
• Cardiovascular effects: Postural hypotension (occurs in 35% of patients), particularly concerning in older adults 1, 4
• Psychiatric symptoms: Anxiety, dysphoria, or rebound symptoms from the underlying condition 3
• Cognitive effects: Confusion or impaired concentration 1

Management of Withdrawal or Worsening Symptoms

• If clinical deterioration occurs during tapering, return to the previous well-tolerated dose and slow the taper further 2
• If symptoms are unstable at any point, maintain therapy at the lowest effective dose rather than proceeding with discontinuation 1
• Patients requiring prolonged therapy at higher doses may not be ideal candidates for rapid tapering 1

Special Considerations

Older Adults

Older persons are particularly prone to postural hypotension and CNS effects with nabilone, requiring extra caution during tapering. 1 The lowest doses should be used, and monitoring for orthostatic changes is essential at each dose reduction. 1

Extended Therapy Duration

Patients on nabilone for extended periods (months to years) may require even slower tapering schedules, potentially extending the taper to 6-12 months with smaller dose decrements. 1, 2 Consider reducing by 25% of the current dose every 2-4 weeks rather than fixed 0.5 mg decrements for these patients. 1

High Incidence of Side Effects

Nabilone has a high incidence of CNS side effects (60-70% experience drowsiness or dizziness), which may paradoxically improve during tapering but could also represent withdrawal. 1, 3 Distinguish between withdrawal symptoms and resolution of medication side effects through careful clinical assessment.

Common Pitfalls to Avoid

• Do not taper too rapidly: Abrupt discontinuation risks CNS irritability and withdrawal symptoms, similar to other centrally-acting medications 1
• Do not skip the extended interval dosing phase: The transition to every-other-day and then every-4-day dosing is critical for minimizing withdrawal 2
• Do not ignore cardiovascular monitoring: Postural hypotension can be severe and unpredictable, particularly in older adults 1, 4
• Do not confuse withdrawal with disease recurrence: If symptoms worsen during tapering, consider whether this represents withdrawal versus return of the underlying condition requiring nabilone 1